Undergraduate training in oncology: An ESO continuing challenge for medical students

Article Outline

• Abstract
• Introduction
• Materials and methods
  • Course design
  • Students selection process
  • Educational programme
  • Examination tests
  • Course evaluation (questionnaire)
• Results
  • Student characteristics
  • Oncology training at several medical schools
  • Course evaluation
  • Evaluation of teaching topics and faculty members
  • Examination scoring, awardees selection and choice of destination for the ESO fellowship
  • Course influence on students career decision towards oncology
• Discussion
• Conflict of interest statement
• Authorship
• Acknowledgements
• References
• Copyright

Abstract 

During the last six years the European School of Oncology (ESO) opened an undergraduate programme for European medical students, aiming to further improve their oncology knowledge and clinical skills. In this endeavour a 5-day course is organized every summer at the University of Ioannina, Greece, where distinguished European oncologists introduce preselected medical students to cancer medicine. The programme includes teaching of several oncological topic regarding diagnosis and treatment of the most common tumours; interactive case presentations and discussions were also incorporated. An overall of 229 medical students, mostly from European medical schools, have been taking part to this intensive summer course, from 2004 to 2009.

This article presents the detailed educational programme, the evaluation results and the outcome of the last six ESO courses; an assessment of the oncological curricula available across European faculties is also presented.

Keywords: Undergraduate medical education, Cancer education, European school of oncology, Oncological training

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Introduction 

Cancer is a major health problem, but medical undergraduate education about cancer medicine is not sufficiently represented, neither it is uniformly delivered across Europe. Undergraduate teaching in oncology among European medical faculties follows a geographical variation. Curricula, modules or syllabi in oncology significantly differ between universities across Europe [1], [2], [3], [4], [5], [6], [7], [8], [9]. This is not dissimilar to other non-European countries [10], [11], [12], [13].

Unfortunately, due to the multidisciplinarity of cancer medicine, clinical oncology is taught separately within the modules of internal medicine or surgery. This often allows less time for medical students to confront with oncology and interact with the cancer patients. Nevertheless, recent relevant data are showing a substantial improvement in cancer undergraduate education in Europe [14].

Due to the recognized deficiency of undergraduate cancer education in Europe, a curriculum in oncology for medical students was proposed in 1998 by an EC/EORTC Workshop, when Deans of medical schools and oncologists from 17 European countries met; it was proposed that each medical school should have an undergraduate oncological curriculum, in order to ensure that newly qualified doctors possess basic skills and knowledge to take part to cancer prevention activities, early diagnosis, as well as curative and palliative management [15].

In recent years several universities have been stablishing elective summer courses in oncology across Europe [16], [17], [18]. Among them, the ESO activity was intended to offer an undergraduate training in oncology to European student doctors [19].

The main aims of the organization of the ESO Medical Students courses are the following: (a) to provide a multidisciplinary oncology teaching from well known European academic experts, (b) to improve the students’ skills through both theoretical knowledge as well as through interactive approach, (c) to be a complimentary teaching to the already existing academic curricula and (d) to try to influence medical students carrier decision towards oncology.

In a previous article published in 2007, we analyzed the results of the first three ESO courses “Oncology for Medical Students” which were organized in collaboration with the University of Ioannina [20]. This paper reports our experience of six consecutive courses held between 2004 and 2009. The educational programme is presented, the students’ characteristics detailed and the courses evaluation is disclosed.

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Materials and methods 

Course design 

The ESO courses for medical students are characterized by: 1) European and non-European 5th–6th year medical students are invited to apply; 2) the course lasts 5 continuous days and focuses on highly prevalent tumours; 3) educational material is being made available to students; 4) every day an afternoon test with multiple-choice questions takes place; 5) the course is promoted through ESO, the European Medical Students’ Association (EMSA) and the Association of Medical Schools in Europe (AMSE); 6) the course is organized in collaboration with the University of Ioannina, Greece and accompanied facilities are provided within the University Campus, in a 3-min walk distance from the lecture room; 7) an educational fellowship programme is granted to the 2-3 students achieving the highest marks as a result of the multiple-choice tests; 8) ESO offers free registration and accommodation to preselected students; 9) the official language of the course is English.

Almost half of the students were informed of the course by word of mouth, i.e. by other students or tutors and about one quarter through ESO mailing or website, respectively.

Students selection process 

Medical students were selected annually by an ESO Committee. The selection criteria were based on the: i) knowledge of English language, ii) curriculum vitae, iii) letter of recommendation from a tutor at their original university and iv) letter of intent written by the student attempting to motivate his/her application and defining his/her expectations. The average number of selected students is approximately 40/year.

Educational programme 

The “ESO Oncology for Medical Students Course” displays an intensive 5-day training programme. Tutorials are clinically orientated and interactive across the whole spectrum of malignant diseases including epidemiology, prevention, presentation of clinical cases, diagnosis and multidimodal therapeutic management (surgery, radiation and systemic treatment). The programme focuses on the most common cancers (breast, lung, colorectal, gastric, prostate, head and neck, uterine and ovarian cancer), but also deals with several “curable tumours” (lymphomas, testicular cancer, pediatric-/adolescence oncology and oncogeriatrics). The teaching programme also includes sessions on specific issues such as biology of cancer, paraneoplastic syndromes, emergencies in oncology, introduction to clinical trials as well as supportive and palliative care. In addition, each session is followed by presentation and discussion of clinical cases. Some lectures also display videos to detail specific aspects of radiotherapy or surgical techniques.

The faculty consists of seven distinguished European academic teachers who are accomplished specialists in medical, surgical oncology or radiation oncology. An educational ESO book of around 500 pages with extended abstracts, references, copies of all presented slides and case presentations is provided to all participants.

Examination tests 

Every afternoon a test takes place, consisting of 30–40 multiple-choice questions related to the topics presented during the same day. The three students achieving the highest score are awarded with 2000 Euros ESO Student Fellowship, to spend one month of clinical training attachment at the department of a faculty member across Europe of his/her choice.

Course evaluation (questionnaire) 

At the beginning of each course an evaluation questionnaire is given to all students asking them to score on a grading scale from 1 to 4 (1 = poor, 2 = satisfactory, 3 = good, 4 = very good).

The questions are related to the evaluation of: (i) the programme objectives, (ii) the organization of the overall learning outcome and (iii) the overall performance of the faculty members (Table 1).

Table 1. Course evaluation questionnaire grading (scale: 4 = very good, 3 = good, 2 = satisfactory, 1 = poor).

Programme objective
01	Please give an overall rating for the quality of the education offered at this course.
02	Was the information useful and relevant to your work and practice techniques?
03	Did you feel that the presented information was well balanced and supported with adequate evidence?
04	Did the programme allow adequate time for discussion and questions with the faculty?
05	How would you rate the quality of educational material (e.g. course book)?
06	Do you think that the course contained designed to promote products?
07	Which part of the course was the most useful and why?
08	Which part of the course was the least useful and why?
09	Do you have suggestions for future course topics?
10	Any further comments, suggestions for improvement?
Programme organization
11	How would you rate the facilities and venue for the purpose of the course?
12	How would you rate the management and organization of the course?
Overall learning outcome
13	The courses should offer participants a qualified training in clinical oncology to improve their knowledge in epidemiology, prevention, diagnosis, treatment and care in the field. Do you think that the course offered the intended aims?
14	Attendees should improve their skills in dealing with cancer problems as a whole challenge and should gain more security to intercourse with them in sense of current best clinical practice and state of the art. Did the meeting provide the goals?
Others
15	How did find out about the course?
	Already participated in ESO activities
	Through advertising in specialist journals
	Though the ESO mailing/Through the ESO website
	Through pharmaceutical companies
	By word of mouth/Other, specify
16	Do you intend to develop your career in oncology?
17	If you are, what specialty will you develop?

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Results 

Student characteristics 

Overall 229 students were selected to participate to the six ESO courses (2004–2009) out of the 460 applications received. The median age was 24 years (range 19–30 years). There was a slight predominance of females. Sixty percent were in their sixth year of medical school and almost 2/3 originated from the European Union (Table 2). A detailed analysis of countries representation is shown in Table 3.

Table 2. Medical Students characteristics (2004–2009).

Number of applicants	460
Number of selected students (%)	229 (50%)
Median age (range)	24 (19–30)
Gender (M/F)	106/123
Years of medical school (% of students)
Sixth	137 (60%)
Fifth	68 (30%)
Below fifth	24 (10%)
Countries of origin
European Union	164 (71.5%)
Non-European Union	56 (24.5%)
Non-Europeans	9 (4%)

Table 3. Countries of origin of medical students.

Oncology training at several medical schools 

Table 4 illustrates how oncology is presently taught; it details the total number of hours of education received in oncology and rates the value of exposure to clinical oncology as reported by students. The analysis of these data highlights how the number of total hours of teaching varies considerably, although oncology teaching is usually compulsory. Also, the rating of clinical exposure of the students to the management of cancer patients is not satisfactory (46% and 26% students rated it as moderate or poor, respectively), with only ¼ students scoring it as satisfactory.

Table 4. Oncology training at various medical faculties.

Curriculum	Total number of students (%)
Oncology teaching
Compulsory Elective	179/226 (79%) 47/226 (21%)
Total hours of oncological teaching
≤10 10–20 20–40 40–60 ≥60	26/219 (11%) 60/219 (27%) 50/219 (23%) 39/219 (17%) 54/219 (24%)
Rating of previous clinical exposure to Oncology
Satisfactory Moderate Poor Other	55/226 (24.5%) 104/226 (46%) 59/226 (26%) 8/226 (3.5%)

Course evaluation 

Table 5 shows the average scores of the 7 most important questions out of the 17 included in the questionnaire (Table 1) administered to all students. These 7 questions refer to the quality, the interaction, the educational material, the facilities, management and organization as well as the aims to improve knowledge and skills. All six courses were highly scored, ranging from 3.39 to 3.81 with an average overall score of 3.65.

Table 5. Overall Course evaluation: Results on the 7 most important questions of the questionnaire.

1 = poor, 2 = satisfactory, 3 = good, 4 = very good.

In details, the overall rating score for each of the 7 most significant questions were 3.65 for the quality, 3.67 for interaction, 3.56 for educational material, 3.68 for facilities, 3.74 for management/organization and 3.61 and 3.56 for improving knowledge and skills, respectively.

Noteworthy, the comparison between the mean scores of the first three courses (2004–2006) and that of the last three courses (2007–2009) indicates stable and continuous trend toward improvement (3.58 versus 3.71).

Evaluation of teaching topics and faculty members 

The evaluation of faculty members was based on the following criteria: (1) quality of presentation, (2) quality of slides, (3) relevance of program objectives, and (4) interaction with students during lecture and clinical case presentations.

The average rating score in all courses is more or less constant ranging between 3.50 and 3.60. The topics with the highest scores were lung cancer (3.77) and lymphoma (3.74). Also, clinical case presentations and discussion were considerably appreciated by the students (3.60). Detailed analysis is demonstrated in Fig. 1 and Table 6.

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• Fig. 1 

  Average scoring evaluation of the quality of the course and of the teaching lectures.

Table 6. Evaluation of faculty members and teaching topics (score 1–4).

Examination scoring, awardees selection and choice of destination for the ESO fellowship 

Table 7 details the awardees, their respective university and country of origin and enumerates the departments where they chose to enjoined spending their ESO Fellowship.

Table 7. Examination scoring of first winners and ESO Fellowship.

The scoring was ranging from 71 to 84%. Out of the 17 winners, 3 were Swiss, 3 Greeks, 3 Italians, 2 Belgians and the rest from UK, Ireland, Turkey, Netherlands, Poland and France.

Nine medical students spent the ESO Fellowship in the following University Hospitals: 5 in Zurich under Professor R. Stahel and R. Seger, 2 in Liverpool under Professor R. Audisio, one in Anterwep under Professor J. Vermorken and one in Valencia under Professor A. Cervantes.

Course influence on students career decision towards oncology 

After the end of the course all students were asked two specific questions with regard to their future medical career. The first question related to whether they intend to develop a career in Oncology. Fifty-one percent replied “perhaps”, 45% “yes” and the rest 4% “no”. The second question was related to what specialty they would prefer to follow if they would intend to develop a career in Oncology. Sixty-one percent favoured Medical Oncology, 24.5% Surgical Oncology, 6% Radiation Oncology and the rest “other oncology specialties”.

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Discussion 

Since 1982 when ESO was first established, most of its educational activities were directed towards doctors as postgraduate training or continuing professional education (CPE). In addition, several training courses for cancer nurses, researchers or even medical secretaries have been organized.

Recently, a new programme was started to improve the education of European medical students in cancer medicine. From 2004 to 2009 six summer courses have taken place at the University of Ioannina, where oncological education was delivered to preselected medical students. This yearly educational effort is still ongoing every year in the city of Ioannina, Greece [20].

Similar elective courses have been organized by other European Institutions such as those from the University of Groningen (International Summer School Oncology for Medical Students – ISOMS), the University of Vienna (International Summer School on Experimental and Clinical Oncology for Medical Students), the International Union Against Cancer (UICC)/World Health Organization (WHO) Collaborating Centre for Cancer Education and the Federation of European Cancer Societies (FECS) in collaboration with partner universities (Universities of Umea’s in Sweden, of Antwerp, Edegem in Belgium, Berlin in Germany and Poznan in Poland) which was supported by the European Community through the Socrates Programme [16], [17], [18].

The aims of the above educational activities differ among them. For example, the University of Vienna’s course was aiming to teach fundamental aspects of cancer biology and basics of diagnostic work-up, clinical oncology and cancer research, whereas the University of Groningen programme intended to help students to become familiar with cancer care and to reduce fear for cancer patients.

From an analysis of 39 students enrolled in the fifth ISOMS Summer School, it was shown that the increase in knowledge was significant and there was a slight change in attitudes towards cancer related problems [17].

Graffan et al., have recently published a review article on the teaching of oncology to undergraduate medical students [21]. Various educational literature databases including MEDLINE, EMBASE, TIMELIT, COCHRANE, etc.; searched and articles were detected on undergraduate teaching in oncology. They came up with several recommendations related to training knowledge, teaching skills and attitudes and teaching professionalism, i.e. improvement of students’ performance in clinical assessment when cancer patients are used to teach breast examination, improvement of students’ sensitivity to detect breast lumps when silicone models are used, and better communication skills when students are directly exposed to cancer patients.

Data from the ESMO phase III MOSES Task Force [14] showed that Medical Oncology is part of the medical curriculum for 53% European medical students, Surgical Oncology in 60%, Radiotherapy in 80%, Clinical Oncology in 93.3%, Haematology in 80% and Palliative Medicine 53.3%. These results are considered as improved data compared to that of MOSES II report [6], [14].

Proper undergraduate education of medical students in cancer medicine is a future investment for adequate health services in our society. Prevention, screening, patient communication skills and palliative care are of paramount importance for primary care services [22]. Such a comprehensive curriculum was proposed in 2006 by the Oncology Education Committee of the Cancer Council Australia and endorsed by the UICC. This “Ideal Curriculum” is focusing on aspects of prevention, screening, diagnosis, treatment and palliative care [23], [24], [25].

Since 2004 ESO has been providing complimentary oncological education to European medical students. In total, 229 medical students had the opportunity to attend six summer courses and to get exposed to an intensive 5-day educational programme. They actively took part into interactive clinical case presentations and they underwent daily exams.

It was noticed how undergraduate education curricula were not uniform across their different medical schools. From the evaluation of the questionnaire it became evident that education in oncology was compulsory in 79% of the European countries, however only 24.5% of the students expressed satisfactory rating of clinical exposure.

The overall evaluation of the course was very encouraging, with an average score of 3.65/4 (range 3.39–3.81). The students’ evaluation showed that they were satisfied with the programme (3.67), the educational material (3.56), the facilities and venue of the course (3.68), the management and the organization (3.74), as well as with the aim of the course to improve knowledge (3.61) and skills (3.56).

Finally, we were very interested to find out whether this ESO Oncology course could affect the future medical students’ career decision. Data analysis showed that half of the students intended to develop a career in Oncology, while the rest had not decided yet. In addition, it was important to discover that the majority of the students were likely to get involved into Medical Oncology.

Our future project is to analyze all replies to a follow-up questionnaire which was recently submitted to all our previous students; this is intended to understand the ultimate outcome of this ESO educational event and to assess whether these medical students eventually chose oncology, several years after their exposure to the ESO Courses.

In conclusion, we believe that ESO provides a successful complimentary undergraduate education in cancer medicine within the European frames and intends to continue to offer this opportunity to all European medical students for the years to come. For the coming years ESMO expressed the interest to co-sponsor this activity with ESO.

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Conflict of interest statement 

None declared.

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Authorship 

Guarantor of the integrity of the study: Nicholas Pavlidis

Study concepts: N. Pavlidis; J. Vermorken; R. Stahel; J. Bernier; A. Cervantes; G. Pentheroudakis; R. Audisio; A. Costa.

Study design: N. Pavlidis; Vermorken; R. Stahel; J. Bernier; A. Cervantes; G. Pentheroudakis; R. Audisio; A. Costa.

Definition of intellectual content: N. Pavlidis; Vermorken; R. Stahel; J. Bernier; A. Cervantes; G. Pentheroudakis; R. Audisio; A. Costa.

Literature research: N. Pavlidis; Vermorken; R. Stahel; J. Bernier; A. Cervantes; G. Pentheroudakis; R. Audisio; A. Costa.

Data acquisition: N. Pavlidis; J. Vermorken; R. Stahel; J. Bernier; A. Cervantes; G. Pentheroudakis; R. Audisio; A. Costa.

Data analysis: Nicholas Pavlidis.

Statistical analysis: Nicholas Pavlidis

Manuscript preparation: Nicholas Pavlidis.

Manuscript editing: N. Pavlidis; J. Vermorken; R. Stahel; J. Bernier; A. Cervantes; G. Pentheroudakis; R. Audisio; A. Costa.

Manuscript review: N. Pavlidis; J. Vermorken; R. Stahel; J. Bernier; A. Cervantes; G. Pentheroudakis; R. Audisio; A. Costa.

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Acknowledgements 

The authors thank: Mrs. C. Melcher (Bellinzona ESO Office), D. Knupfer (Bellinzona Office), Mrs. A. Tsitou (Ioannina Office), Mrs. D. Stamouli (Ioannina Office), Dr. V. Golfinopoulos (Ioannina University Hospital), Dr. L. Kostadima (Ioannina University Hospital), Dr. A. Nearchos (Ioannina University Hospital), Dr. E. Voulgaris (Ioannina University Hospital) and Dr. K. Stoyianni (Ioannina University Hospital) for their great help in the organization of the ESO Course.

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